Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0689
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Level of Harm - Actual harm
Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE
FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS
SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.
Based on observation, medical record review, hospital documentation review, staff interview, review of a
personnel file, review of disciplinary action documentation, review of an investigation, policy review, and
review of facility initiated corrective action, the facility failed to ensure appropriate care and assistance was
provided to prevent a resident fall. This resulted in actual harm when Resident #64 was transferred by a
mechanical (Hoyer) lift using only one staff member to assist, and subsequently fell, causing a closed right
forearm fracture and a facial contusion. This affected one (#64) of three residents reviewed for falls. The
facility census was 64.
Findings include:
Review of Resident #64's medical record revealed the resident was admitted to the facility on [DATE] and
expired on [DATE]. Resident #64 was admitted to Hospice services on [DATE]. Diagnoses included but not
limited to atherosclerosis of coronary artery bypass grafts, syncope and collapse, metabolic
encephalopathy, chronic kidney disease, hypertensive heart disease, rotator cuff tear or rupture of right
shoulder, anxiety, depression, and unspecified convulsions.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 had moderately
impaired cognition and was dependent to extensive assist for activities of daily living.
Review of the plan of care revealed Resident #64 had a potential for falls related to disease processes and
interventions included two assist for Hoyer transfers.
Review of the progress note dated [DATE] at 1:00 P.M. revealed at around 5:25 A.M. writer was alerted by
the Certified Residential Care Associate (CRCA) that assistance was needed as quickly as possible to
Resident #64's room. Upon entering the room, Resident #64 was laying on her back with head close to the
door. The writer observed resident to be alert with CRCA on resident's left side and nurse to the right. The
nurse appeared to be tending to a wound on the right side of the resident's forehead. Resident #64 was
whimpering in pain as right wrist appears to be in abnormal alignment. The writer asked other staff
members what happened and it was stated the resident leaned forward, causing her to slip out of the Hoyer
lift and fall to the floor. The writer continued to help with first aid and then went to the nurses' station to call
for the rescue squad. The squad arrived at approximately 5:45 A.M. and the resident was assisted onto a
gurney. The resident was transported to the emergency room (ER) at approximately 5:50 A.M.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 4
Event ID:
365841
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365841
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/27/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Valley View Health Campus
1247 North River Rd
Fremont, OH 43420
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Actual harm
Residents Affected - Few
Review of the Interdisciplinary Team (IDT) note dated [DATE] at 2:30 P.M. revealed Resident #64 was being
assisted to wheelchair from the bed. CRCA #611 reported the Hoyer lift snagged on a blanket and the
resident fell out of the sling. Resident #64 was assessed by the nurse and transferred to the ER for
evaluation. Interventions included to ensure the resident's floor was free of hazard, ensure care plan is
followed, and ensure appropriate sling is used.
Review of the lift evaluation dated [DATE] at 2:34 P.M. revealed Resident #64 is to use a Hoyer sling that
crosses between the legs.
Review of the written statement from CRCA #611 dated [DATE] revealed at approximately 5:30 A.M. CRCA
#611 went to get Resident #64 from the bed to the wheelchair. CRCA #611 stated she raised the resident
high enough to move her over to the chair. CRCA #611 stated the Hoyer lift snagged on a blanket and the
resident fell forward out of the sling. CRCA #611 stated the resident landed on her right side and CRCA
#611 had to move the resident because she was partially laying on the lift leg. CRCA #611 stated the
resident was approximately at chair height when she fell. CRCA #611 stated she called for help. CRCA
#611 stated all four sling parts were still intact after the resident fell.
Review of the hospital documentation dated [DATE] revealed Resident #64 was seen for closed right
forearm fracture, pneumonia, sinusitis, fall, and contusion of face. No surgical intervention was needed at
that time. Resident #64 was sent back to facility on [DATE] with a sling to the right arm and a follow up
appointment for orthopedics to be scheduled in four days.
Interview on [DATE] at 1:02 P.M. with Director of Health Services (DOHS) #800 verified CRCA #611
transferred Resident #64 with the Hoyer lift by herself. DOHS #800 verified the sling was the appropriate
size. DOHS #800 verified CRCA #611 was disciplined. DOHS #800 verified Resident #64's plan of care
prior to the fall reflected the resident was two assist for Hoyer transfers.
Interview on [DATE] at 2:37 P.M. with CRCA #611 verified she transferred Resident #64 by herself with the
Hoyer lift. CRCA #611 verified she used the sling that was in the resident's wheelchair that was previously
used. CRCA #611 stated the resident was trying to get out of bed and had fallen out of bed a few days
earlier so she figured she should get her up before it happened again. CRCA #611 stated she had folded
the blankets down at the foot of the bed and when she went to transfer the resident, the Hoyer sling got
caught on the blankets and it tipped the resident out of the sling. CRCA #611 stated the Hoyer was lifted
about wheelchair level when the resident slid out and fell onto her right side. CRCA #611 stated the
resident hit her head during the fall, but her right arm took most of the impact. CRCA #611 verified she was
educated on proper use of Hoyer lift and in-serviced on slings, how many assist is required, and preformed
return demonstrations. CRCA #611 verified she received a written warning and was suspended until the
investigation was completed.
Review of CRCA #611's personnel file revealed on [DATE] CRCA #611 was provided education regarding
two person lifts and total lifts.
Review of disciplinary action document dated [DATE] for CRCA #611 revealed CRCA #611 received a
written warning for failing to follow plan of care profile guidelines which resulted in injury to a resident and
CRCA repositioned the resident prior to nurses' assessment. CRCA #611 was also suspended on [DATE]
until the investigation was completed.
Review of the facility policy titled, Guidelines for Resident Utilizing a Lift, dated [DATE] revealed all devices
are safe to be used by one staff member per manufactures guidelines. Staff should
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365841
If continuation sheet
Page 2 of 4
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365841
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/27/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Valley View Health Campus
1247 North River Rd
Fremont, OH 43420
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
seek the assistance of a second person for those residents' care planned for assistance of two with the
lifting device or as needed for safe handling.
Level of Harm - Actual harm
Residents Affected - Few
The deficient practice was corrected on [DATE] when the facility implemented the following corrective
action:
•
On [DATE] at approximately 5:25 A.M., Resident #64 slid out of a Hoyer sling and fell to the floor when
CRCA #611 transferred the resident by herself.
•
On [DATE] at approximately 5:45 A.M., the rescue squad arrived at the facility.
•
On [DATE] at approximately 5:50 A.M., the rescue squad took Resident #64 to the ER to be checked out
due to an abrasion to her head and possible right wrist fracture.
•
On [DATE] through [DATE], DOHS #800 completed education regarding care plans and Hoyer policy to all
CRCAs.
•
On [DATE], DOHS started demonstrations with nursing staff regarding Hoyer lifts.
•
On [DATE], the Administrator and DOHS #800 initiated audits to observe proper Hoyer lift transfers.
•
On [DATE], the Administrator initiated Quality Assurance and Performance Improvement (QAPI) and ad
hoc.
•
On [DATE], DOHS #800 reviewed weights for all residents using a Hoyer lift and verified correct slings were
in residents' rooms.
•
On [DATE], DOHS #800 and the Administrator placed education on color guidance charts for sling sizes to
the inside of each hall storage closets.
•
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365841
If continuation sheet
Page 3 of 4
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365841
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/27/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Valley View Health Campus
1247 North River Rd
Fremont, OH 43420
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
On [DATE] through [DATE], Scheduling Coordinator/CRCA #692 sent messages through staff app for
mandatory meeting regarding Hoyer protocol to all nursing staff.
Level of Harm - Actual harm
•
Residents Affected - Few
On [DATE], the Administrator verified Environmental was following manufacturer guidelines for sling
washing and handling.
•
On [DATE] at 12:12 P.M., the Administrator verified with Plant Operations #801 that mechanical lift
inspections were completed for the last 12 months.
•
On [DATE], DOHS #800 updated care plans on Hoyer transfers, proper sling use and care profiles.
•
On [DATE], DOHS #800 verified all Hoyer lift residents were made two assist for transfers with a Hoyer.
•
On [DATE] through [DATE], DOHS #800 completed a re-cap of education via staff app.
•
On [DATE], DOHS #800 and the Administrator initiated an audit tool for CRCA knowledge of resident
profiles and how to access.
•
On [DATE], DOHS #800 reviewed and updated the nurse aide registry.
•
On [DATE], DOHS #800 and Administrator verified the new hire competency checklist for Hoyer transfers.
•
Review of audits revealed the facility observed two resident's Hoyer transfers, three times a week for four
weeks, then weekly for eight weeks as needed/QAPI.
This deficiency represents non-compliance investigated under Complaint Number OH00150629.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365841
If continuation sheet
Page 4 of 4
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
FAQ · About this visit
Common questions about this visit
What happened during the February 27, 2024 survey of VALLEY VIEW HEALTH CAMPUS?
This was a inspection survey of VALLEY VIEW HEALTH CAMPUS on February 27, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at VALLEY VIEW HEALTH CAMPUS on February 27, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.